Should patients be educated about the medications they are getting, or that are available to them, while they are in the hospital?
Ethan Cumbler, ACP Member, and his colleagues at the University of Colorado at Denver think so. Their recent study, published online Dec. 10 in the Journal of Hospital Medicine, shows many inpatients don't know most of their medications.
The researchers asked 50 cognitively intact adult internal medicine inpatients to list medications they believed had been prescribed for them in the hospital. Ninety-six percent omitted one or more of their inpatient medications. On average the patients omitted 60% of their medications—which came to almost seven forgotten drugs per patient. At the same time, more than three-quarters of the patients said they would like to have received a medication list, but only 28% said they had actually seen one.
Those patients who have the capacity and interest to learn about their inpatient medications should be educated, said Dr. Cumbler, an assistant professor of internal medicine at the University of Colorado. Such patients may be able to catch potential medication errors—a significant cause of in-hospital medical mistakes, he noted.
Yet other hospital care experts say too much education about medication can actually make patients more confused than too little education. This may occur, for example, if the medications a patient was on at home were stopped in the hospital, or if certain in-hospital medications were given for less than 24 hours, noted Allen Vaida, PharmD, executive vice president of the Institute for Safe Medication Practices.
Some patients—such as those with dementia, severe conditions or poor health literacy—also may not be willing or able to keep track of the medications they are getting, Dr. Vaida said. Indeed, 38% of the admissions in Dr. Cumbler's study were excluded from the study for reasons such as not knowing their outpatient medications, not speaking English, and having a history of dementia.
Educating every patient may not be realistic, Dr. Cumbler acknowledged, and there is a danger in educating patients in the wrong way. “There is absolutely potential to introduce confusion if you try to provide a list of medicines without explanations and without a mechanism to keep the patient abreast of changes,” says Dr. Cumbler.
Still, the practice holds promise. In a pilot study, Dr. Cumbler's group had hospital staff educate 20 patients about their inpatient medications. A research assistant translated medication lists into consumer-readable language. About half the pilot patients gave feedback or asked questions about their medication, and in a few instances, the patient feedback resulted in minor changes to their medication regimen. In at least one case, a patient identified a potentially major safety problem before it caused harm, Dr. Cumbler said.
The right way to educate
While Dr. Cumbler's JHM study wasn't designed to explain how inpatient medication education should be done, he and other experts have some ideas. For starters, an education program might use graded participation based on individual patients' interest and ability, which would address the problem of trying to educate patients who are unwilling or unable to learn, Dr. Cumbler said.
Appropriate patients could then be given a list of the medications they receive in the hospital, preferably in advance of the first administration of the drugs, he added.
“If a patient is first given the name of a new medication at the time of administration, this may be disconnected from the patient's understanding of how the medication fits into the overall care plan,” Dr. Cumbler said.
Dr. Vaida, however, thinks it's best to tell patients about a medication at the time it's to be given, rather than burdening them with a list of medications they may struggle to remember. In addition, physicians should recite their patients' medications aloud at the bedside while making rounds, rather than just reviewing them on their own or with other team members outside the room.
These simple actions can help catch any potential medication errors before they occur, but won't drain hospital finances with extensive education efforts, Dr. Vaida said. For patients who may be interested, health care team members can also make them aware that their nurses have a list of patient medications, and that it's OK to ask which medications are on the list, and why, he added.
Don't explicitly talk about medical errors when you tell patients about medications, Dr. Cumbler warned.
“The more questions are phrased in terms of detecting medical error, the less patients are comfortable with that role,” Dr. Cumbler said. “You can tell them that if they have any questions or concerns, to bring them up, which is going to have a very different feel to it.”
On a broader level, hospitals need to address the fact that inpatient medication records are written in language most patients don't understand, Dr. Cumbler said. Hospital formularies also may result in automatic substitutions for some medications that patients were taking prior to admission, which may be confusing to patients, he said.
Being able to rattle off a list of inpatient medications isn't as important as a patient knowing about the drugs she was taking when she came in the hospital—and will be taking when she leaves, some experts say.
Brian J. Clay, ACP Member, a hospitalist and associate professor of medicine at the University of California, San Diego, said the main goal should be to prepare patients for life after discharge.
“The emphasis should be on what the patient needs to know for when they are not surrounded by a hospital infrastructure. The earlier that we can do that, I think, the better served the patient is,” Dr. Clay said.
Currently, such education tends not to be started until near or at the end of a patient's stay, but ideally it would occur during several sessions, over several days, and with both patients and caregivers, he added.
Hospitalists should take advantage of the inpatient stay to go over the medications patients have been taking before admission to make sure they still need them, Dr. Vaida said.
“The biggest issue that we see,” he said, is that patients are already on many medications, and it's difficult to discern which ones they should continue. Often, health professionals are just checking whether a list is correct, rather than making sure all the medications are still necessary, Dr. Vaida said.
Education about outpatient medications isn't mutually exclusive with education about inpatient medication, Dr. Cumbler noted. And both will involve a major commitment on the part of hospitalists and hospitals alike.
“A very simple concept requires very large and sweeping changes to systems in order to be practical on a large scale,” said Dr. Cumbler. “But there is potential here.”